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Zorluk: OrtaRheumatology and Immunology

A 28-year-old man visits the clinic complaining of persistent lower back pain that has bothered him for the past 6 months. He notes that the pain is most severe upon awakening and is accompanied by significant stiffness that gradually improves after about an hour of moving around. He works as a landscaper and reports that physical activity throughout the day relieves his discomfort, whereas rest exacerbates it. He takes ibuprofen occasionally, which provides partial relief. His vital signs are within normal limits. Physical examination demonstrates limited forward flexion of the lumbar spine and tenderness upon palpation over the sacroiliac region. There are no sensory or motor deficits in the lower extremities, and straight-leg raise testing is negative bilaterally. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

  1. Plain radiography of the sacroiliac jointsCevap
  2. B
    Measurement of serum HLA-B27 antigen
  3. C
    Magnetic resonance imaging of the lumbar spine
  4. D
    Serum rheumatoid factor and anti-cyclic citrullinated peptide testing
  5. E
    Electromyography of the lower extremities

Cevap

Plain radiography of the sacroiliac joints is the most appropriate initial step to evaluate for sacroiliitis.
This patient's presentation of insidious, chronic lower back pain that is worse in the morning and improves with physical activity is classic for inflammatory back pain, raising strong suspicion for ankylosing spondylitis. The hallmark of ankylosing spondylitis is sacroiliitis. The most appropriate initial step in diagnostic evaluation is plain radiography of the sacroiliac joints, which can reveal subchondral sclerosis, erosions, and joint space narrowing.

Adım Adım Çözüm

1
Analyze the patient's demographic and clinical presentation.
The patient is a young male with a 6-month history of chronic lower back pain that is worse in the morning, improves with exercise, and worsens with rest.
This pattern is highly characteristic of inflammatory back pain, rather than mechanical back pain.
2
Formulate a primary differential diagnosis.
The clinical picture strongly suggests a seronegative spondyloarthropathy, specifically ankylosing spondylitis.
Ankylosing spondylitis typically presents in young men with inflammatory back pain and stiffness involving the axial skeleton.
3
Determine the optimal initial diagnostic test.
Plain radiography (X-ray) of the sacroiliac joints is selected.
Demonstrating sacroiliitis on imaging is required for the diagnosis of ankylosing spondylitis, and plain X-ray is the most appropriate, cost-effective first step.

Anahtar Kavram

Ankylosing spondylitis presents with inflammatory back pain that improves with activity and worsens with rest; the initial diagnostic step is plain radiography of the sacroiliac joints to identify sacroiliitis.
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